Episode 19: Burns Part 1

Author: Eoghan Colgan    @eoghan_colgan
Special Guest: Stuart Watson

08/08/18


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Guest Bios

Stuart Watson

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Mr Stuart Watson is a Consultant Burns and Plastic Surgeon at the Canniesburn Unit in Glasgow Royal Infirmary, as well as a Director of ReSurge Africa. He is also one of the european representatives on the Executive Committee of the International Society for Burn Injuries (ISBI) and a member of the steering group of the ISBI developing international guidelines for care of burn injuries.


Show Notes

Eoghan and Stuart discuss the management of burn injuries including pre-hospital care, emergency management and follow-up. In this episode they cover all uncomplicated burns (from superficial to full-thickness) including first-aid, analgesia, dressings, blister debridement and when to consider surgery..


Take Home Points

PREHOSPITAL CARE

  1. Remove from scalding agent and remove clothing
  2. Small burns:
    • 20 minutes of cool running water on burn
      • reduces depth of burn and excellent for pain relief
      • can do at home if no urgency to get to hospital
  3. Larger burns:
    • brief cooling for 1-2 minutes to avoid hypothermia (especially kids and older adults)
    • then cool soaked cloths on the burn and can replenish the water
  4. Room temperature water is good but a little colder is better
    • Avoid ice (can cause additional tissue damage)

 

DEPTH OF BURNS

  1. Erythema (1st degree)
    • sunburn and scalds
    • skin unbroken but red/inflamed and often very painful
    • needs cooling and analgesia but doesn't require fluid resuscitation
  2. Superficial partial thickness (2nd degree)
    • epidermis is blistered off
    • has a bright pink/red/inflamed and moist surface
    • blanches on pressure (circulation is intact)
    • looks superficial and skin is alive and healthy
  3. Deeper partial thickness or deep dermal (2nd degree)
    • has fixed staining (no blanching)
    • varying colours such as white, orange or red
    • takes a longer time to heal and often will benefit from surgery
  4. Full thickness (3rd degree)
    • leathery appearance (look and feel)
    • dry, hard and inelsastic
    • NOTE: some flame injuries can be white and hard to tell from normal skin

 

MANAGEMENT

All burns:

  1. Ensure comfortable
  2. Good history of how it happened
    • try to identify what the burning agent is
  3. Good ABCDE assessment and always exclude other potential injuries
  4. Consider NAI in kids
  5. If not had any first-aid then apply it now

Erythema (1st degree)

  1. Apply cold running water (20mins) and assess if skin broken or not
  2. Analgesics: standard WHO guidelines (paracetamol, weak opiates and ibuprofen)
  3. Dressings:
    • typically leave undressed
    • could cover if likely high-chance of abrasion (e.g. across a major joint)
      • could use a non-adhesive dressing (e.g. paraffin gauze or silicone-based dressing)
    • if on face - hydrogel dressings ca be excellent at relieving pain
  4. Discharge advice:
    • keep out of sun and drink fluids
    • elevate and rest burned limbs
    • skin tends to dry so could use a simple (fragrance-free) moisturiser after a few days to avoid dryness and easy comfort
  5. No follow-up typically required

Superficial partial thickness (2nd degree)

  1. Blistering:
    • strongest evidence is to remove blistered skin
      • they can get larger and more uncomfortable, or
      • they can burst and the dead skin is a breeding ground for infection
    • give them analgesia in advance (cocodamol for adults or diamorphine IN for kids)
  2. Analgesics:
    • 20mins of cooling
    • standard WHO guidelines (paracetamol, weak opiates and ibuprofen)
    • face - hydrogel dressing is a good choice for pain relief
  3. Dressings:
    • NOTE:
      • children have a small but significant risk of life-threatening (toxic shock) infection, even in small burns
      • these burns tend to have signifiant exudate leak over the first 24-48 hours
    • Basic Emergency Management:
      • ADULT:
        • inexpensive, gelonet dressing, covered with an absorbent gauze and held in place with a bandage
        • bigger areas may benefit from topical antiseptic (as for children)
        • in the perineum or perianal areas then a silver-based cream (such as Flamazine) is useful
      • CHILDREN:
        • minimise risk of toxic-shock syndrome
          • silver-impregnated dressing such as Urgotul SSD, or
          • jelonet/mepitel non-adhesive, with mupirocin underneath, and gauze/bandage on top, or
          • inadine dressing with gauze and bandage on top
    • Follow-up within 24-48 hours
      • Practice nurse if uncomplicated
      • Secondary care if complicated (burns nurse or dressing clinic):
        • arger (e.g. >1%), children/elderly, complicated injuries (joints, face, feet, perineum etc)
      1. reevaluate the depth/size of burn
        • all burns have a great capacity to change depth and extent in first 5 days
      2. check for signs of infection
        • unlikely to have overt infection within 1-2 days but might be developing subtle signs
        • consider a wound swab if 'not quite right'
      3. change of dressing
        • these burns produce a lot of exudate which needs changed at 24-48 hours
        • could then switch to a hydrocolloid-type dressing
          • create a moist wound-healing environment to optimise speed of healing
            • not suitable initially due to exudate (change to this at 1st or 2nd visit back)
          • also have a lower adherence to wound than jelonet or mepitel

Deep Partial thickness or deep dermal (2nd degree)

  • Generally the same first-aid principles apply
  • NOTE: main concern is the greater risk of a poorer functional or aesthetic result
    • is it likely to take longer than 3 weeks to heal (and avoid a thick/hypertrophic scar)??
      • >2cm (or any size in child) - best to refer
      • if tiny then look after for 10 days (reassess every 2-3 days) and refer then if not progressing
      • in-between = use judgement

Full thickness (3rd degree)

  • Similar basic first-aid but generally less painful when occurred
  • Start thinking 'could it be more complex'
    • can be '4th degree' = damage to deeper structures
    • generally dead, dry and tight and has tendency to constrict acting as a tourniquet
    • therefore: check distal neuromuscular function in limbs and ensure airway ok in face/neck injuries 
  • Refer all patients with full thickness burns for consideration of surgery
    • they will heal faster, with less risk of infection and less likelihood to develop thick, hypertrophic scarring
      • remember there will still be a scar after surgery
    • if very small (or patient unfit for surgery)then could offer to dress and monitor

 

WHAT HAPPENS TO FULL THICKNESS BURNS (that are not operated on)

  • dressed for a few weeks with a dressing that softens the dead skin which will lift off over several weeks
  • this will leave an equivalently-sized area of granulation tissue underneath
  • the wound is vulnerable to infection during this period
    • large open wound
    • big patch of dead tissue on top that is a breeding ground for infection
  • when dead skin sloughed off then wound will gradually heal from the sides by contraction
    • high-risk of severe contraction at joints with impaired function
  • High risk of hypertrophic scar
    • delayed healing (>3 weeks) stimulates production of collagen protein in the care to an excessive degree

 

THE PROBLEM WITH JOINTS

  1. NOTE:
    • burn injuries restrict movement during healing and impede function
    • after healing scarring can cause contracture which interferes with function
  2. generally dressed with joint extended
  3. if any doubt then involve physiotherapy to asses ROM and provide exercises to optimise ROM
  4. if slow to heal then liaise with surgeon to consider benefits of surgery in first 2 weeks
    • burn that takes >3/52 to heal has an increased risk of becoming a thick, hypertrophic scar


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